© 2015 Zywave, Inc. All rights reserved. This document is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. The information contained herein, including its attachments, contains proprietary and confidential information. Any distribution of these materials to third parties is strictly prohibited.

Section 6056 Reporting Workbook Instructional Guide

Step-by-step Instructions for the Section 6056 Reporting Workbook

The Section 6056 Reporting Workbook can be used to help

employers record the information needed to satisfy new

reporting requirements added by the Affordable Care Act

(ACA), under Internal Revenue Code Section 6056. This new

reporting provision requires applicable large employers

(ALEs) subject to the ACA’s employer shared responsibility

rules to report information to the IRS and to full-time

employees about offers of health coverage for their full-time

employees. Reporting under Section 6056 is first required in early 2016 for coverage offered (or not offered) in 2015.

The Section 6056 Reporting Workbook does not generate any IRS forms or complete any sections of IRS forms for

reporting entities. Instead, the Reporting Workbook is intended to help reporting entities record and keep track of the

information needed in order to do this reporting. The Section 6056 Reporting Workbook should not be filed with the IRS or

relied upon for filing. However, please contact GBS Benefits, Inc. for information about options for completing the forms.

Also, please note that the information contained in the Section 6056 Reporting Workbook and this Instructional Guide is

based on final versions of 2015 forms and instructions provided by the IRS. Forms and instructions for 2015 reporting

have not been finalized by the IRS. More information is available in the Section 6056 final regulations, IRS Q&As on

Section 6056, IRS Q&As on Form 1094-C and Form 1095-C and the final forms and instructions. An Overview of

Information Reporting by Applicable Large Employers is also available on the IRS website.

OVERVIEW OF THE SECTION 6056 REPORTING WORKBOOK

The Section 6056 Reporting Workbook is intended to be used by ALEs subject to the ACA’s employer shared

responsibility rules. An ALE is an employer that employed, on average, at least 50 full-time employees (including full-time

equivalent employees) on business days during the prior calendar year. All employers that employ at least 50 full-time

employees (including full-time equivalent employees) are subject to the ACA’s employer shared responsibility rules,

including for-profit, nonprofit and government employers.

ALEs that have 50 to 99 full-time employees (including full-time equivalent employees) on business days during 2014 may

qualify for a one-year delay from the employer shared responsibility rules, until 2016. However, reporting under Section 6056 for 2015 is still required for these employers.

© 2015 Zywave, Inc. All rights reserved. This document is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. The information contained herein, including its attachments, contains proprietary and confidential information. Any distribution of these materials to third parties is strictly prohibited.

Each page of the Section 6056 Reporting Workbook where information must be entered corresponds to a specific form

that must be filed with the IRS under Section 6056. Each page indicates the IRS form number, as well as the part and line

of the form to which the specific information on that page relates. The forms that must be filed with the IRS under Section

6056 include:

• Form 1094-C, which is a transmittal that reports summary information for each employer and transmits Forms

1095-C to the IRS; and

• Form 1095-C, which is an employee statement that must be filed for each full-time employee to report information

about the health coverage offered (or not offered) to each full-time employee.

This Instructional Guide is divided into sections based on each page of the Section 6056 Reporting Workbook. It provides

step-by-step instructions for using the Section 6056 Reporting Workbook, as well as helpful hints and tips. It also provides

some limited background information when necessary.

PAGE 1—WELCOME

This page provides a basic overview of the Section 6056 reporting requirements, and allows users to easily navigate to

various pages of the Reporting Workbook for more information or to begin recording data.

TIP: Helpful hints and useful information are provided throughout the Section 6056 Reporting Workbook. Use your cursor to hover over the red question marks in the Workbook (like the one shown on the left here) to view the information.

Each page of the Reporting Workbook will have a “HOME” button in the upper left corner

(indicated either as “HOME” or using this symbol: ). By clicking the “HOME” button, the tool

will navigate the user to the Welcome page.

Use the “START” button to begin recording the information needed to satisfy the Section 6056

reporting requirements. By clicking the “START” button, the tool will navigate the user to the first

page where information must be recorded—the Form 1094-C Basic Employer Information page.

Use the “Background” button to read background information on the Section 6056 reporting

requirements. By clicking the “Background” button, the tool will navigate the user to the

Background page, which provides a basic overview of the Section 6056 reporting requirements.

Use the “IRS Guidance” button to access official IRS guidance on the Section 6056 reporting

requirements. By clicking the “IRS Guidance” button, the tool will navigate the user to the IRS

Guidance page, which provides links to final regulations, Q&As and final forms and instructions.

Use the “More Info” button to explore more detailed information on the Section 6056 reporting

requirements. By clicking the “More Info” button, the tool will navigate the user to the More

Information page, which provides access to specific information related to Section 6056 reporting.

© 2015 Zywave, Inc. All rights reserved. This document is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. The information contained herein, including its attachments, contains proprietary and confidential information. Any distribution of these materials to third parties is strictly prohibited.

PAGE 2—FORM 1094-C: BASIC EMPLOYER INFORMATION

This page is used to record basic identifier and contact information for the employer that is needed to complete Form

1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns (a transmittal form

that is used to submit Forms 1095-C to the IRS). Some of the information recorded on this page may also be helpful for

completing Part I of Form 1095-C, Employer-Provided Health Insurance Offer and Coverage.

The light green box on this page contains instructions for using the Form 1094-C: Basic Employer Information page. The

light green box also contains a note on the Authoritative Transmittal. In general, one Form 1094-C (called the

Authoritative Transmittal) must be filed for each ALE to report aggregate employer-level data for all full-time employees,

even in cases in which multiple Forms 1094-C are filed by (or on behalf of) the ALE. This Form 1094-C must be identified

as the Authoritative Transmittal on Line 19 of Part I. For example, if an ALE has prepared a separate Form 1094-C for

each of its two divisions to transmit Forms 1095-C for each division’s full-time employees, one of the Forms 1094-C filed

must be designated as the Authoritative Transmittal and report aggregate employer-level data for all full-time employees

of the ALE (the employees of both divisions).

In the dark green “General Information” box:

• Enter the total number of Forms 1095-C submitted with the Form 1094-C transmittal. In general, one Form

1095-C must be filed for each of the ALE’s full-time employees, regardless of whether coverage was offered to

each full-time employee. There must be only one Form 1095-C for each full-time employee of that ALE. For

example, if an ALE separately reports for the full-time employees of its two divisions, the ALE must combine the

information for any employee who worked at both divisions during the calendar year, so that there is only a single

Form 1095-C for that employee, which reports information for all 12 months of the calendar year.

• Certify using the drop-down menu whether a designated government entity (DGE) is filing on behalf of the ALE. In general, an ALE that is a governmental unit may report under Section 6056 on its own behalf or may

appropriately designate another person (or persons) that is part of (or related to) the same governmental unit to

report on its behalf. If “Yes” is selected in the drop-down menu, an additional section will appear on this page

where additional information will need to be entered.

• Certify using the drop-down menu whether the ALE was a member of an Aggregated ALE Group during any month of the calendar year. For purposes of determining whether an employer is an ALE, all persons

treated as a single employer under Code Section 414(b), (c), (m) or (o) are treated as one ALE, called an

Aggregated ALE Group. If an ALE is made up of only one person or entity, that one ALE is not a part of an

Aggregated ALE Group. For purposes of Section 6056, each member of an Aggregated ALE Group must file a

return with the IRS and furnish a statement to its full-time employees, using its own EIN, even if a particular ALE

Note: The Section 6056 Reporting Workbook does not distinguish between the Authoritative Transmittal and any other Forms 1094-C that may be filed by (or on behalf of) the ALE. Users are responsible for identifying an Authoritative Transmittal when filing with the IRS, and for ensuring that all information entered and/or filed with the IRS complies with all applicable requirements.

© 2015 Zywave, Inc. All rights reserved. This document is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. The information contained herein, including its attachments, contains proprietary and confidential information. Any distribution of these materials to third parties is strictly prohibited.

member individually does not employ enough employees to qualify as an ALE. If “Yes” is selected in the drop-

down menu, an additional section will appear on this page where additional information will need to be entered.

• Certify using the drop-down menu whether the ALE is reporting information on self-insured coverage that it sponsors. An ALE that offers health coverage through an employer-sponsored self-insured health plan must

also report under Code Section 6055 about each individual who is enrolled in the self-insured coverage. To do

this, Form 1095-C and the Section 6056 Reporting Workbook include a separate section to report the information

required under Section 6055. If “Yes” is selected in the drop-down menu, the ALE will have to complete the

“Covered Individuals” page of the Section 6056 Reporting Workbook.

The “Employer” section relates to identifier and contact information for the ALE. Under this section:

• Enter the employer’s name.

• Enter the employer’s nine-digit employer identification number (EIN), including the dash. The ALE’s EIN may not

be truncated on any forms filed with the IRS or furnished to recipients. A Social Security number (SSN) may not

be entered in lieu of an EIN.

• Enter the employer’s complete address (including room or suite number, if applicable). This address should match

the employer’s address used on the Form 1095-C.

The “Employer’s Contact Person” section relates to identifier and contact information for the ALE’s contact person who is

responsible for answering any questions. In this section, enter the name and telephone number for the contact person.

If “Yes” is selected in the drop-down menu to certify that a DGE is filing on behalf of the ALE, this section will appear. If

“No” is selected in the drop-down menu to certify that a DGE is not filing on behalf of the ALE, this section does not have

to be completed—skip to the next section.

If a DGE is filing on behalf of the ALE, the following additional identifier and contact information will need to be entered for

the DGE under this section:

• Enter the DGE’s name.

• Enter the DGE’s nine-digit EIN, including the dash. The DGE’s EIN may not be truncated on any forms filed with

the IRS or furnished to recipients. A Social Security number (SSN) may not be entered in lieu of an EIN.

Note: A valid EIN is required at the time any Form 1094-C is filed. If a valid EIN is not provided, the Form 1094-C will not be processed. If the employer does not have an EIN, it may apply for one online at www.IRS.gov, or by faxing or mailing Form SS-4, Application for Employer Identification Number, to the IRS. See the Instructions for Form SS-4, or Publication 1635, Employer Identification Number, for more information.

© 2015 Zywave, Inc. All rights reserved. This document is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. The information contained herein, including its attachments, contains proprietary and confidential information. Any distribution of these materials to third parties is strictly prohibited.

• Enter the DGE’s complete address (including room or suite number, if applicable).

• Enter the name and telephone number of the DGE’s contact person who is responsible for answering any

questions related to the Form 1094-C.

If “Yes” is selected in the drop-down menu to certify that the ALE was a member of an Aggregated ALE Group during one

or more months of the calendar year, this section will appear. If “No” is selected in the drop-down menu to certify that the

ALE was not a member of an Aggregated ALE Group during any month of the calendar year, this section does not have to

be completed—skip to the next section.

If the ALE was a member of an Aggregated ALE Group for any month of the calendar year, enter the name(s) and EIN(s)

of up to 30 of the other Aggregated ALE Group members in descending order, listing first the member with the highest

average monthly number of full-time employees. If there are more than 30 members of the Aggregated ALE Group, enter

the 30 with the highest monthly average number of full-time employees for the year (or for the number of months during

which the ALE Member was a member of the Aggregated ALE Group).

Click the “HOME” button to return to the Welcome page.

Click the “NEXT” button to continue to the next page—the Form 1094-C: Detailed Employer Information page.

Click the “BACK” button to return to the previous page.

PAGE 3—FORM 1094-C: DETAILED EMPLOYER INFORMATION

This page is used to record more detailed information for the employer that is needed to complete certain parts of Form

1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns. The light green box

on this page contains background information on the parts of Form 1094-C to which the information on this page relates.

Line 22 of Part II on Form 1094-C requires each ALE to certify whether it is eligible for certain special rules under the

Section 6056 reporting requirements or the Section 4980H employer shared responsibility rules. Part III of Form 1094-C

requires each ALE to provide certain information for each month (unless the information is consistent for the entire year).

Under the “Certifications of Eligibility” section, the ALE will certify whether it meets the eligibility requirements for, and is

using, one of the alternative methods of reporting under Section 6056 and/or one of the forms of transition relief under the

Section 4980H employer shared responsibility rules. The alternative methods of reporting under Section 6056 allow ALEs

Note: A valid EIN is required at the time any Form 1094-C is filed. If a valid EIN is not provided, the Form 1094-C will not be processed. If the employer does not have an EIN, it may apply for one online at www.IRS.gov, or by faxing or mailing Form SS-4, Application for Employer Identification Number, to the IRS. See the Instructions for Form SS-4, or Publication 1635, Employer Identification Number, for more information.

© 2015 Zywave, Inc. All rights reserved. This document is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. The information contained herein, including its attachments, contains proprietary and confidential information. Any distribution of these materials to third parties is strictly prohibited.

to report simplified Section 6056 return information to the IRS and provide simplified employee statements for certain

employees. The transition relief under the Section 4980H provides some relief from penalties for certain ALEs. Click the

links provided in each box under the “Certifications of Eligibility” section for more information.

In the “Qualifying Offer Method” box, certify (by selecting “Yes” or “No” in the drop-down menu) whether the ALE is

eligible for, and is using, the Qualifying Offer Method for one or more full-time employees. The Qualifying Offer Method is

an alternative reporting method available to ALEs that made a Qualifying Offer to one or more of its full-time employees

for all months during the year in which the employee was a full-time employee for whom an employer shared responsibility

penalty could apply. To be eligible to use the Qualifying Offer Method, the ALE must:

• Offer minimum essential coverage providing minimum value to one or more full-time employees for all 12 months

during the calendar year for which the employee was a full-time employee for whom a Section 4980H employer

shared responsibility penalty could apply, at an employee cost for employee-only coverage for each month not

exceeding 9.5 percent of the mainland single federal poverty line divided by 12; and

• Offer minimum essential coverage to the employee’s spouse and dependents (if any).

Click the link provided in the “Qualifying Offer Method” box for more information on the Qualifying Offer Method.

In the “Qualifying Offer Method Transition Relief” box, certify (by selecting “Yes” or “No” in the drop-down menu) whether

the ALE is eligible for, and is using, the Qualifying Offer Method Transition Relief for 2015. The Qualifying Offer Method

Transition Relief for 2015 is available to ALEs that made a Qualifying Offer for one or more months of the calendar year

2015 to at least 95 percent of their full-time employees. Solely for 2015, ALEs that made a Qualifying Offer to at least 95

percent of their full-time employees (and their spouses and dependents) may report under Section 6056 using the

Qualifying Offer Method for all employees.

Click the link provided in the “Qualifying Offer Method Transition Relief” box for more information on the Qualifying Offer

Method Transition Relief for 2015.

Note: These rules are separate from the employer shared responsibility rules. Although the employer shared responsibility rules do not require employers to offer spousal coverage, employers that wish to use the Qualifying Offer Method to report under Section 6056 must offer minimum essential coverage to spouses and dependent children. Employers that are not eligible to use the Qualifying Offer Method must use the general method of reporting under Section 6056.

Also, the employer shared responsibility final rules provide transition relief for certain employers that do not offer dependent coverage in 2015. An employer using this transition relief will not be treated as offering dependent coverage under the Qualifying Offer Method.

Note: These rules are separate from the employer shared responsibility rules. Although the employer shared responsibility rules allow employers to satisfy the “substantially all” standard by offering coverage to 70 percent of their employees (and dependents) in 2015, employers that wish to use the Qualifying Offer Method Transition Relief to report under Section 6056 must offer coverage to at least 95 percent of their employees in 2015. Employers that are not eligible to use the Qualifying Offer Method Transition Relief must use the general method of reporting under Section 6056.

© 2015 Zywave, Inc. All rights reserved. This document is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. The information contained herein, including its attachments, contains proprietary and confidential information. Any distribution of these materials to third parties is strictly prohibited.

In the “Section 4980H Transition Relief Based on Number of Full-Time Employees” box, certify (by selecting “Yes” or “No”

in the drop-down menu) whether either of the two types of Section 4980H Transition Relief Based on Number of Full-Time

Employees apply for the ALE. If certain eligibility conditions are met, an ALE may be eligible for one of the following two

types of 2015 transition relief under the Section 4980H employer shared responsibility rules, based on the ALE’s number

of full-time (and full-time equivalent, or FTE) employees.

• 50-99 Transition Relief: If certain eligibility conditions are met, an ALE that has 50 to 99 full-time (and FTE)

employees on business days in 2014 will not be subject to a Section 4980H penalty for any month in 2015.

• 100 or More Transition Relief: If an ALE that has 100 or more full-time (and FTE) employees on business days

in 2014 is subject to a Section 4980H(a) penalty in 2015 for failing to offer coverage to substantially all full-time

employees and dependents, the ALE may reduce its number of full-time employees by 80 (rather than by 30)

when calculating the penalty amount.

Click the link provided in the “Section 4980H Transition Relief Based on Number of Full-Time Employees” box for more

information on the two types of Section 4980H Transition Relief Based on Number of Full-Time Employees.

In the “98% Offer Method” box, certify (by selecting “Yes” or “No” in the drop-down menu) whether the ALE is eligible for,

and is using, the 98% Offer Method. The 98% Offer Method is an alternative reporting method available to ALEs that, for

all months of the calendar year, offered affordable, minimum value coverage to at least 98 percent of their employees

(and dependents) that are reported on a Form 1095-C filed for the ALE.

Click the link provided in the “98% Offer Method” box for more information on the 98% Offer Method.

Under the “Monthly Information” section, ALEs will provide certain information related to each month using the table

provided. This information is needed to complete Part III of Form 1094-C. Note that some rows in this table may not be

available, based on answers previously selected.

There are grey instructional boxes below the table, which provide specific instructions on how to complete each line.

On the “Minimum Essential Coverage Offer Indicator” line of the table, indicate whether the ALE offered minimum

essential coverage under an employer-sponsored plan to substantially all full-time employees and dependents for each

Note: These rules are separate from the employer shared responsibility rules. Although the employer shared responsibility rules allow employers to satisfy the “substantially all” standard by offering coverage to 70 percent of their employees (and dependents) in 2015, employers that wish to use the 98% Offer Method to report under Section 6056 must offer coverage to at least 98 percent of their employees (and dependents) that are reported on a Form 1095-C filed for the ALE. Employers that are not eligible to use the 98% Offer Method must use the general method of reporting under Section 6056.

© 2015 Zywave, Inc. All rights reserved. This document is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. The information contained herein, including its attachments, contains proprietary and confidential information. Any distribution of these materials to third parties is strictly prohibited.

month of the calendar year. Click the link provided in the grey “Minimum Essential Coverage Offer Indicator” instructional

box below the table for more information on offers of minimum essential coverage.

• For each month in 2015 (and any months of the 2015 plan year that fall in 2016, for non-calendar year plans), an

ALE satisfies the "substantially all" standard if it offers coverage to at least 70 percent of its full-time employees

(and dependents).

• For years after 2015, an ALE satisfies the "substantially all" standard if it offers coverage to at least 95 percent of

its full-time employees (and dependents). If the ALE offered coverage to all but five of its full-time employees

(and dependents), and if five is greater than 5 percent of the ALE’s number of full-time employees, the ALE may

report for each month as if it offered coverage to at least 95 percent of its full-time employees (and dependents).

If the ALE offered coverage to substantially all

full-time employees (and dependents) for the entire calendar year:

• Select “Yes” in the “ALL” box

If the ALE offered coverage to substantially all

full-time employees (and dependents) only for certain months of the calendar year:

• Select “Yes” in the applicable box for the

months coverage was offered

• Select “No” in the applicable box for the

months coverage was not offered

If the ALE did not offer coverage to substantially

all full-time employees (and dependents) for any month of the calendar year:

• Select “No” in the “ALL” box

Note: An employee in a Limited Non-Assessment Period is not counted in determining whether minimum essential

coverage was offered to substantially all of an ALE’s full-time employees (and dependents). Click the link in the grey

“Minimum Essential Coverage Offer Indicator” instructional box for more information on Limited Non-Assessment Periods.

On the “Full-Time Employee Count for ALE” line of the table, enter the ALE’s number of full-time employees for each month, but do not include any employee in a Limited Non-Assessment Period. If the ALE’s number of full-time employees

in a month is zero, enter 0. Click the link provided in the grey “Full-Time Employee Count for ALE” instructional box for

more information on full-time employee status and Limited Non-Assessment Periods.

© 2015 Zywave, Inc. All rights reserved. This document is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. The information contained herein, including its attachments, contains proprietary and confidential information. Any distribution of these materials to third parties is strictly prohibited.

Note: If “Yes” is selected in the “98% Offer Method” box above to certify that the ALE is using the 98% Offer Method, this

line of the table will not be available and does not have to be completed.

On the “Total Employee Count for ALE” line of the table, enter the ALE’s total number of employees for each month,

including both full-time and non-full-time employees. An ALE must choose to use one of the following days to determine

the number of employees per month and must use the same day for all months of the year:

(1) The first day of each month;

(2) The last day of each month;

(3) The 12th day of each month;

(4) The first day of the first payroll period that starts during each month; or

(5) The last day of the first payroll period that starts during each month (provided that, for each month, that last day

falls within the calendar month in which the payroll period starts).

If the total number of employees was the same for every month of the entire calendar year, enter that number in the “ALL”

box. If the number of employees for any month is zero, enter 0.

On the “Aggregated ALE Group Indicator” line of the table, certify the month(s) of the calendar year (if any) in which the

ALE was a member of an Aggregated ALE Group.

• If the ALE was an Aggregated ALE Group member for all 12 months of the calendar year, enter an “X” in the

“ALL” box.

• If the ALE was a member of an Aggregated ALE Group for some, but not all, months of the calendar year, enter an “X” in the corresponding box for each month in which it was a member of an Aggregated ALE Group.

Note: If “No” is selected on the Form 1094-C: Basic Employer Information page to certify that the ALE was not a member

of an Aggregated ALE Group for any month of the calendar year, this line of the table will not be available and does not

have to be completed.

On the “Section 4980H Transition Relief Indicator” line of the table, certify the type of Section 4980H Transition Relief

Based on Number of Full-Time Employees for which the ALE is eligible. An employer cannot be eligible for both.

• Select Code A if the ALE is eligible for the 50-99 Relief.

• Select Code B if the ALE is eligible for the 100 or More Relief.

© 2015 Zywave, Inc. All rights reserved. This document is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. The information contained herein, including its attachments, contains proprietary and confidential information. Any distribution of these materials to third parties is strictly prohibited.

Click the link provided in the grey “Section 4980H Transition Relief Indicator” instructional box for more information on the

two types of Section 4980H Transition Relief Based on Number of Full-Time Employees.

Note: If “No” is selected in the “Section 4980H Transition Relief Based on Number of Full-Time Employees” box to certify

that the ALE is not eligible for either of the Section 4980H Transition Relief Based on Number of Full-Time Employees,

this line of the table will not be available and does not have to be completed.

Click the “HOME” button to return to the Welcome page.

Click the “NEXT” button to continue to the next page—the Form 1095-C: Employee Information page.

Click the “BACK” button to return to the Form 1094-C: Basic Employer Information page.

PAGE 4—FORM 1095-C: EMPLOYEE INFORMATION

This page is used to record all of the information needed to complete Form 1095-C, Employer-Provided Health Insurance

Offer and Coverage. ALEs must report information on Forms 1095-C about each employee who was a full-time employee

of the ALE for any month of the calendar year, regardless of whether health coverage was (or was not) offered to the employee. In general, one Form 1095-B must be filed for each full-time employee.

The light green box on this page contains instructions for using the Form 1095-C: Employee Information page. Each step

of the instructions is color-coded along with the section of the table to which that step relates. Some of the information on

this page is reported using indicator codes provided by the IRS. The light green box also contains links that provide

detailed information on these indicator codes, as well as a link that provides information on when an employee’s birthdate

may be reported in lieu of a Social Security number.

The blue section of the table relates to identifier and contact information for each full-time employee. Under this section:

• Enter the name of each full-time employee of the ALE (first name, middle initial, last name).

• Enter the nine-digit SSN for each full-time employee (111-11-1111), including the dashes. ALEs may truncate the

SSN of a full-time employee on any Forms 1095-C furnished to individuals, by showing only the last four digits of

the SSN and replacing the first five digits with asterisks (*) or X’s.

• Enter the complete mailing address of each full-time employee (including apartment number, if applicable). A

country code is not required for U.S. addresses.

Note: Reporting of SSNs for all full-time employees is necessary for the IRS to verify an individual’s coverage without the need to contact the individual. If an ALE is unable to obtain an SSN after making a reasonable effort to do so, the employee’s date of birth (MM/DD/YYYY) may be entered in lieu of an SSN. However, an ALE may be subject to penalties for failing to report an SSN if it cannot demonstrate to the IRS that it properly solicited the SSN but did not receive it. Click the link provided in the light green instructions box of the Reporting Workbook for more information.

© 2015 Zywave, Inc. All rights reserved. This document is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. The information contained herein, including its attachments, contains proprietary and confidential information. Any distribution of these materials to third parties is strictly prohibited.

The pink column of the table relates to the plan start month. This box is optional for 2015 and the employer may leave it blank; it is anticipated that this box will be mandatory for 2016.

To complete the box, enter the two-digit number (01 through 12) indicating the calendar month during which the plan year

begins for the health plan in which the employee is offered coverage (or would be offered coverage, if the employee were

eligible to participate in the plan). If more than one plan year could apply (for instance, if the employer changes the plan

year during the year), enter the earliest applicable month. If there is no health plan under which coverage is offered to the

employee, enter “00”.

The orange section of the table relates to the type of health coverage offered by (or on behalf of) the ALE to the

employee, the employee’s spouse and the employee’s dependents, if any. A code must be entered for each calendar month January through December, even if the employee was not a full-time employee for one or more of those months.

• An employer offers health coverage for a month only if it offers health coverage that would provide coverage for

every day of that calendar month. If an employee terminates coverage before the last day of the month, the

employee does not actually have an offer of coverage for that month. See Code 2B, later, for how the employer

may complete this section in the event an employee terminates coverage before the last day of the month.

• Under this section, select the applicable code for each calendar month to identify the type of health coverage

actually offered by (or on behalf of) the ALE to the employee, if any. Do not enter a code for any other type of

health coverage the employer is treated as having offered (but the employee was not actually offered coverage).

If the employee was not actually offered coverage, enter Code 1H (no offer of coverage).

• For this purpose, an offer of coverage is treated as having been made to an employee’s dependents only if the

offer of coverage is made to an unlimited number of dependents regardless of the actual number of dependents, if

any, an employee has during any particular calendar month.

• An offer of COBRA continuation coverage that is made to a former employee upon termination of employment

should not be reported as an offer of coverage. For a terminated employee, Code 1H (No offer of coverage)

should be entered for any month for which the offer of COBRA continuation coverage applies. An offer of COBRA

continuation coverage that is made to an active employee (for instance, an offer of COBRA continuation

coverage that is made due to a reduction in the employee’s hours that resulted in the employee no longer being

eligible for coverage under a plan) is reported in the same manner and using the same code as an offer of that

type of coverage to any other active employee.

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If the same code applies for all 12 calendar months, enter the applicable code in the “ALL” box, and do not complete the

individual calendar month boxes. When a code is selected in the “ALL” box, the boxes for each month will be darkened to

indicate to the user that information should not be entered in any of those boxes (as illustrated in the example below).

When a code is selected in a box for any month, the “ALL” box will be darkened to indicate to the user that information

should not be entered in the “ALL” box (as illustrated in the example below).

Click the link provided in the light green instructions box for a description of each Offer of Coverage indicator code. The

following table provides an overview of each Offer of Coverage indicator code (Code Series 1):

Code Description

1A

Qualifying Offer:

• Minimum essential coverage providing minimum value offered to full-time employee with employee

contribution for self-only coverage equal to or less than 9.5 percent of the mainland single federal poverty

line; and

• At least minimum essential coverage offered to spouse and dependent(s).

TIP: This code may be used to report for specific months for which a Qualifying Offer was made, even if the

employee did not receive a Qualifying Offer for all 12 calendar months. However, an ALE may not provide a

simplified employee statement for an employee who did not receive a Qualifying Offer for all 12 calendar months.

1B • Minimum essential coverage providing minimum value offered to employee only.

1C • Minimum essential coverage providing minimum value offered to employee; and

• At least minimum essential coverage offered to dependent(s) (not spouse).

1D • Minimum essential coverage providing minimum value offered to employee; and

• At least minimum essential coverage offered to spouse (not dependent(s)).

1E • Minimum essential coverage providing minimum value offered to employee; and

• At least minimum essential coverage offered to dependent(s) and spouse.

1F

Minimum essential coverage NOT providing minimum value offered to:

• Employee; or

• Employee and spouse or dependent(s); or

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• Employee, spouse and dependent(s).

1G

Offer of coverage to employee who:

• Was not a full-time employee for any month of the calendar year; and

• Enrolled in self-insured coverage for one or more months of the calendar year.

1H

No offer of coverage (employee not offered any health coverage or employee offered coverage that is not

minimum essential coverage, which may include one or more months in which the individual was not an

employee).

For 2015, an ALE relying on multiemployer arrangement interim guidance should enter Code 1H in this section of

the table for any month for which the ALE enters Code 2E in the “Applicable Section 4980H Safe Harbor” section

(indicating that the ALE was required to contribute to a multiemployer plan on behalf of the employee for that

month and therefore is eligible for multiemployer interim rule relief). For 2015, Code 1H may be used without

regard to whether the employee was eligible to enroll or enrolled in coverage under the multiemployer plan. For

reporting for 2016 and future years, ALEs relying on the multiemployer arrangement interim guidance may be

required to report offers of coverage made through a multiemployer plan in a different manner.

1I

Qualifying Offer Transition Relief 2015: Employee (and spouse or dependent(s)) received:

• No offer of coverage;

• An offer that is not a qualifying offer; or

• A qualifying offer for less than 12 months.

The green section of the table relates to the employee’s cost for the plan. Under the green “Employee Share of the

Lowest Cost Monthly Premium for Self-Only Minimum Value Coverage” column of the table, enter the amount (including

any cents) of the employee share of the lowest-cost monthly premium for self-only minimum essential coverage providing

minimum value that is offered to the employee. This amount may not be the amount the employee is paying for the coverage, for example, if the employee chose to enroll in more expensive coverage (such as family coverage).

For purposes of determining the monthly employee contribution, an employer may divide the total employee share of the

premium for the plan year by the number of months in the plan year to determine the monthly employee contribution for

the plan year. This monthly employee contribution would then be reported for any months of that plan year that fall in the

2015 calendar year.

Note: This line must be completed only if Code 1B, 1C, 1D or 1E is selected for any month in the “Offer of Coverage” column. If the ALE did not offer health coverage, or it offered health coverage that was not minimum essential coverage or did not provide minimum value, do not complete this line. Also, ALEs that are eligible for the Qualifying Offer Method or the Qualifying Offer Method Transition Relief for an employee do not have to complete this line for that employee.

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• If the employee is offered coverage but is not required to contribute any amount towards the premium, enter

“0.00” (do not leave blank).

• If the employee share of the lowest-cost monthly amount was the same amount for all 12 calendar months, enter

that monthly amount in the “ALL” box, and do not complete the monthly boxes. When an amount is entered in the

“ALL” box, the boxes for each month will be darkened to indicate to the user that information should not be

entered in any of those boxes (as illustrated in the example below).

• If the employee share of the lowest-cost monthly amount was not the same for all 12 months, enter the amount in

each calendar month for which the employee was offered minimum value coverage. If an “X” is entered in a box

for any month, the “ALL” box will be darkened to indicate to the user that information should not be entered in the

“ALL” box (as illustrated in the example below).

The purple section of the table relates to the type of Section 4980H Safe Harbor or other relief (if any) for which the ALE is

eligible. Under this section, select the applicable code (if any) indicating the Section 4890H Safe Harbor or other relief for

which the ALE is eligible. These codes indicate that one of the following situations applied to the employee:

• The employee was not employed or was not a full-time employee;

• The employee enrolled in the minimum essential coverage offered;

• The employee was in a Limited Non-Assessment Period with respect to Section 4980H(b);

• Non-calendar year transition relief applied to the employee;

• The employer met one of the Section 4980H affordability safe harbors with respect to this employee; or

• The employer was eligible for multiemployer interim rule relief for this employee.

In some circumstances, more than one situation could apply to the same employee in the same month. For example, an

employee could be enrolled in health coverage for a particular month during which he or she is not a full-time employee.

However, only one code may be used for a particular calendar month. The instructions below address which code to

use for a month if more than one code from Series 2 could apply.

For any month in which an employee enrolled in minimum essential coverage, Code 2C (reporting enrollment) should be

used instead of any other indicator code that could also apply (for example, the code for a Section 4980H affordability

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safe harbor) (however, see the exception to this rule below regarding the multiemployer interim rule relief). If Code 2C is

used for an employee for a month, do not use any other code in this code series for that month (except Code 2E).

Note that if the employee enrolled in employer-sponsored coverage, the IRS will not need any further information to

determine the ALE’s compliance with the employer shared responsibility rules or an employee’s eligibility for a subsidy.

Employees who are enrolled in employer-sponsored coverage are not eligible for a subsidy (regardless of whether the

coverage is affordable or provides minimum value), and therefore cannot trigger a penalty for the ALE. Thus, if Code 2C is

used, an ALE will not need to indicate anywhere else that any affordability safe harbor was used for that month.

• If the same code applies for all 12 calendar months, enter the applicable code in the “ALL” box. Do not complete

individual calendar month boxes. When a code is selected in the “ALL” box, the monthly boxes will be darkened to

indicate that information should not be entered in any of those boxes (as illustrated in the example below).

• If a code is selected in a box for any month, the “ALL” box will be darkened to indicate to the user that information

should not be entered in the “ALL” box (as illustrated in the example below).

• If none of the codes apply for a calendar month, leave the line blank for that month.

The following table provides an overview of each Safe Harbor or Other Relief indicator code (Code Series 2):

Code Description

2A

Employee not employed during the month. Use this code if the employee was not employed on any day of the

calendar month. Do not use this code for:

• A month if the individual was an employee of the employer on any day of the calendar month; or

• The month during which an employee terminates employment with the employer.

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2B

Employee not a full-time employee. Use this code if the employee is not a full-time employee for the month and

did not enroll in minimum essential coverage, if offered, for the month. Also use this code:

• If the employee is a full-time employee for the month, but his or her offer of coverage (or coverage, if the

employee was enrolled) ended before the last day of the month solely because the employee terminated

employment during the month (so that the offer of coverage or coverage would have continued if the

employee had not terminated employment during the month); or

• For January 2015, if the employee was offered health coverage no later than the first day of the first

payroll period that begins in January 2015 and the coverage offered was affordable for purposes of the

employer shared responsibility rules and provided minimum value.

2C

Employee enrolled in coverage offered. Use this code for any month in which the employee enrolled in health

coverage offered by the employer for each day of the month, regardless of whether any other code in Code

Series 2 (other than Code 2E) might also apply (for example, the code for an affordability safe harbor under the

employer shared responsibility rules). Do not use this code:

• If Code 1G is entered in the “ALL” box in the “Offer of Coverage” section because the employee was not

a full-time employee for any months of the calendar year; or

• For any month in which a terminated employee is enrolled in COBRA coverage (use Code 2A).

2D

Employee in a Section 4980H(b) Limited Non-Assessment Period. Use this code for any month during which

an employee is in a Limited Non-Assessment Period under the employer shared responsibility rules. If an

employee is in an initial measurement period, use this code for the month, and not Code 2B (employee not a full-

time employee). For an employee in a Limited Non-Assessment Period for whom the ALE is also eligible for the

multiemployer interim rule relief for the month, use Code 2E (multiemployer interim rule relief) and not this code.

2E

Multiemployer interim rule relief. Use this code for any month for which the multiemployer arrangement interim

guidance applies for that employee, regardless of whether any other code in Code Series 2 (including Code 2C)

might also apply. Although ALEs may use the affordability safe harbors to determine affordability for purposes of

the multiemployer arrangement interim guidance, an ALE eligible for this relief for a month for an employee

should enter this code, and not a code for the affordability safe harbors (Codes 2F, 2G, or 2H).

Under the multiemployer interim rule relief, an employer is treated as offering health coverage to an employee if

the employer is required by a collective bargaining agreement or related participation agreement to make

contributions for that employee to a multiemployer plan that offers, to individuals who satisfy the plan’s eligibility

conditions, health coverage that is affordable and provides minimum value, and that also offers health coverage

to those individuals’ dependents.

2F Section 4980H affordability Form W-2 safe harbor. Use this code if the ALE used the Form W-2 safe harbor to

determine affordability for this employee for the year. If an ALE uses this safe harbor for an employee, it must be

used for all months of the calendar year for which the employee is offered health coverage.

2G Section 4980H affordability federal poverty line safe harbor. Use this code if the ALE used the federal

poverty line safe harbor to determine affordability for this employee for any month(s).

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2H Section 4980H affordability rate of pay safe harbor. Use this code if the ALE used the rate of pay safe harbor

to determine affordability for this employee for any month(s).

2I

Non-calendar year transition relief applies to this employee. Use this code if non-calendar year transition

relief for the employer shared responsibility rules applies to this employee for the month. Under certain

circumstances, an ALE that sponsors a non-calendar year health plan may be eligible for certain transition relief

for some or all of its employees for the period during 2015 before the beginning of the 2015 plan year.

Click the “HOME” button to return to the Welcome page.

Click the “NEXT” button to continue to the next page—the Form 1095-C: Covered Individuals page.

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PAGE 5—FORM 1095-C: COVERED INDIVIDUALS

This page is used to record all of the information needed to complete Part III of Form 1095-C, Employer-Provided Health

Insurance Offer and Coverage. This part is used by ALEs for combined reporting under both Section 6056 and Section

6055. Section 6055 reporting applies to all providers of minimum essential coverage, including self-insured plan sponsors.

An ALE should complete Part III of Form 1095-C ONLY if it offers employer-sponsored self-insured health coverage in

which any employee or other individual enrolled. For this purpose, employer-sponsored self-insured health coverage does

not include coverage under a multiemployer plan.

An ALE Member with a self-insured major medical plan and a health reimbursement arrangement (HRA) is required to

report the coverage of an individual enrolled in both types of minimum essential coverage under only one of the

arrangements. An ALE Member with an insured major medical plan and an HRA is not required to report HRA coverage of

an individual if the individual is eligible for the HRA because the individual enrolled in the insured major medical plan. An

ALE Member with an HRA must report coverage under the HRA in Part III for any individual who is not enrolled in a major

medical plan of the ALE Member (for example if the individual is enrolled in a group health plan of another employer (such

as spousal coverage)).

• Part III of Form 1095-C must be completed by an ALE offering self-insured health coverage for any individual

who was an employee for one or more calendar months of the year (whether full-time or non-full-time) and who

enrolled in the coverage. If two or more employees employed by the same employer are spouses (or employee

and dependent), and one employee enrolled in a coverage option under the plan that also covered the other

employee(s) (for example, one employee spouse enrolled in family coverage that provided coverage to the other

employee spouse and their employee dependent child), the enrollment information should be reflected only on the

This page should be completed ONLY if the ALE provides self-insured coverage. ALEs that provide coverage through an insurance policy should not complete this page.

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Form 1095-C for the employee who enrolled in the coverage (but would report the other employee family

members as covered individuals).

• Part III of Form 1095-C may be completed by an ALE offering self-insured health coverage for any other

individual who enrolled in the coverage under the plan for one or more calendar months of the year but who was

not an employee for any calendar month of the year (such as a non-employee director, a retired employee who

retired in a previous year, a terminated employee receiving COBRA coverage who terminated employment during

a previous year or a non-employee COBRA beneficiary, but not including an individual who obtained coverage

through the employee’s enrollment, such as a spouse or dependent obtaining coverage when an employee elects

family coverage). Alternatively, ALEs may use Forms 1094-B and 1095-B to report coverage for these individuals

and their family members.

If the Form 1095-C is used with respect to an individual who was not an employee for any month of the calendar

year, use Code 1G in the “ALL” box in the “Offer of Coverage” Column on the Form 1095-C: Employee

Information page, and do not complete the remaining columns of that table.

All employee family members that are covered individuals through the employee’s or individual’s enrollment (for example,

because the employee elected family coverage) must be included on the same form as the employee (or the individual to

whom the offer was made).

The light green box on this page contains instructions for using the Form 1095-C: Covered Individuals page. Each step of

the instructions is color-coded along with the section of the table on this page to which that step relates. The light green

box also contains a link that navigates the user to a page that provides detailed information on when a birthdate of a

covered individual may be reported in lieu of a Social Security number.

The blue section of the table relates to identifier and contact information for each covered individual. Under this section:

• Enter the name of each covered individual. This includes all individuals actually enrolled in the minimum essential

coverage for any month during the calendar year.

• Enter the nine-digit SSN for each covered individual (111-11-1111), including the dashes, or other Taxpayer

Identification Number (TIN) issued by the IRS. ALEs may truncate the SSN or other TIN, as applicable, of a

covered individual on any Forms 1095-C furnished to individuals, by showing only the last four digits of the SSN

and replacing the first five digits with asterisks (*) or X’s.

Note: Reporting of SSNs or TINs for all covered individuals is necessary for the IRS to verify an individual’s coverage without the need to contact the individual. If an ALE is unable to obtain an SSN after making a reasonable effort to do so, the covered individual’s date of birth (MM/DD/YYYY) may be entered in lieu of an SSN. However, an ALE may be subject to penalties for failing to report an SSN if it cannot demonstrate to the IRS that it properly solicited the SSN but did not receive it. Click the link provided in the light green instructions box for more information.

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The green section of the table relates to the employee associated with the covered individual. Under this section, select

the name of the employee who enrolled the individual in the coverage from the drop-down menu.

Note: For this section to work properly, the Form 1095-C: Employee Information page must first be completed.

The orange section of the table relates to the months during the calendar year that each individual was covered under the

self-insured employer-sponsored plan. Under this section, enter an “X” in the applicable box(es) for each month in which

the individual was covered for at least one day.

• If the individual was covered for at least one day per month for all 12 months of the calendar year, enter an “X” in

the “ALL” box. Do not enter an “X” in any other box. If an “X” is entered in the “ALL” box, all of the other boxes will

be darkened to indicate to the user that information should not be entered in those boxes (as illustrated in the

example below).

• If the individual was not covered for all 12 months of the calendar year, enter an “X” in the applicable box(es) for

each month in which the individual was covered for at least one day. Do not enter an “X” in the “ALL” box. If an

“X” is entered in a box for any month, the “ALL” box will be darkened to indicate to the user that information

should not be entered in the “ALL” box (as illustrated in the example below).

Click the “HOME” button to return to the Welcome page.

Click the “BACK” button to return to the Form 1095-C: Employee Information page.

PAGE 6—OFFER OF COVERAGE INDICATOR CODES

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This page provides a description of the Offer of Coverage indicator codes provided by the IRS that are used to report the

type of health coverage offered by (or on behalf of) the ALE to an employee. These codes are entered in the “Offer of

Coverage” column of the table on the Form 1095-C: Employee Information page of the Reporting Workbook.

Click the “HOME” button to return to the Welcome page.

Click the “BACK” button to return to the Form 1095-C: Employee Information page.

PAGE 7—4980H SAFE HARBOR INDICATOR CODES

This page provides a description of the Section 4980H Safe Harbor (and other relief) indicator codes provided by the IRS

that are used to report the Section 4980H relief for which the ALE is eligible (if any). These codes indicate that, under a

rule or safe harbor, the ALE will not be subject to a penalty under Section 4980H(b) for the month, or that the health

coverage offered will be treated as affordable for purposes of Section 4980H(b). These codes are entered in the

“Applicable Section 4980H Safe Harbor” column of the table on the Form 1095-C: Employee Information page of the

Reporting Workbook.

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PAGE 8—BACKGROUND

This page provides an overview of the reporting requirements under Section 6056. It includes basic information about

entities that are required to report, the forms that must be filed and the filing deadlines. It also includes information on how

to report under Section 6056, including an electronic filing requirement and the combined reporting method that will be

used to report under both Section 6056 and the related Section 6055 reporting requirement.

Click the “HOME” button to return to the Welcome page.

PAGE 9—IRS GUIDANCE

This page provides access to official guidance issued by the IRS on the Section 6056 reporting requirements. Using the

links provided on this page, users can access the IRS’ final regulations under Section 6056, IRS Questions and Answers

and final forms and instructions.

Click the “HOME” button to return to the Welcome page.

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PAGE 10—MORE INFORMATION

This page provides access to more specific information on the Section 6056 reporting requirements. Using the links

provided on this page, users can access information on the reporting methods, Section 4980H transition relief, important

definitions and circumstances under which a birthdate may be reported in lieu of a Social Security number (SSN).

Click the “HOME” button to return to the Welcome page.

PAGE 11—REPORTING METHODS

This page provides an overview of the methods of reporting under Section 6056. The IRS has provided a general method

for filing Section 6056 returns, as well as two alternative methods that may be used for specific groups of employees.

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PAGE 12—SECTION 4980H TRANSITION RELIEF

This page provides an overview of various types of Section 4980H transition relief and how an ALE reports its eligibility for

any particular type of relief. An ALE eligible for this relief must still report under Section 6056 for 2015.

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PAGE 13—DEFINITIONS

This page contains definitions of key terms used for reporting under Section 6056.

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PAGE 14—REPORTING A BIRTH DATE IN LIEU OF A SOCIAL SECURITY NUMBER

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This page provides an overview of the circumstances under which a reporting entity may report a covered individual’s

birthdate in lieu of a Social Security number (SSN).

Click the “HOME” button to return to the Welcome page.

Click the “BACK” button to return to the Form 1095-C: Employee Information page.